Addressing Chronic Homelessness

There is no doubt that the experience of homelessness is difficult and troubling for anyone who experiences it. Having said that, it is also necessary to differentiate the homeless population in terms of length and severity of experience. A useful way of differentiating the population is to consider those who are Chronically Homeless (individuals who are homeless for a year or more, usually for a long time), Episodically Homeless (those who move in and out of homelessness) and Transitionally Homeless (short-term, usually less than a month).

The chronically homeless are individuals who have been on the streets for a long time, potentially years. Interestingly, the number of chronically homeless people in Canada, as a percentage of the homeless population is between 2-4%, and is considerably lower than is the case in the United States (10%).

In the State of Homelessness in Canada: 2013 we estimated the annual number of chronic and episodically homeless shelter users to be 10,000 to 30,000 nationally. The Londerville and Steele study estimates the number of absolutely homeless (rough sleepers) to be 5,000, of which 3,000 are chronically or episodically homeless. Combining the two figures, the total number of chronically or episodically homeless individuals in Canada is estimated to be somewhere between 13,000 to 33,000 people.

Why is it necessary to distinguish between duration and type of homelessness?

It is because though episodically and chronically homeless individuals and families account for less than 15% of the homeless population, their personal struggles – mental and physical health issues, addictions, legal and justice issues, discrimination – tend to be much more severe. Moreover, in spite of their smaller numbers, they, in fact, consume more than half the resources in the homelessness system, including emergency shelter beds and day programs. Because of the rigours of life on the streets, this group is much more likely to experience catastrophic health crises requiring medical intervention, and a high level of run-ins with law enforcement. The flip side of this of course is that for over 90% of the people who experience homelessness in a year, their homelessness is almost entirely the result of poverty and housing availability and affordability.

Prioritizing Chronic Homelessness

The first State of Homelessness in Canada report showed that while the number of people experiencing chronic or episodic homelessness is relatively low (4,000-8,000 and 6,000-22,000 respectively), the system incurs great expenses in providing them care. As a result, most communities place a priority on ending chronic and episodic homelessness. Once these populations receive housing and supports, only a minimal emergency homelessness support structure will be needed to assist people who suffer from very short-term, emergency homelessness.

There are compelling reasons to prioritize chronically and episodically homeless persons and give them first claim on permanent housing, despite the fact that they make up less than 20% of the homeless population. First, it is they who suffer the most. We know from research that the longer one is homeless, the more one’s health and well-being declines. There is a greater likelihood of experiencing criminal victimization and trauma, and addictions can worsen as people seek to self-medicate. Run-ins with the law become more common and incarceration becomes an increasing possibility. Social and economic isolation increases, making it much more challenging to get off the streets and reintegrate into the community.

Homelessness Partnering Strategy (HPS) and Chronic Homelessness

As part of its focus on Housing First, the Homelessness Partnering Strategy (Canada’s funder to local communities for homelessness is expecting its 61 Designated Communities to prioritize chronically and episodically homeless persons. According to Directive 1 of the Homelessness Partnering Strategy Directives 2014-2019, after a community has managed to house “90% of its chronic and episodic homeless population, it may focus the Housing First interventions on the group with the next highest needs.”

HPS has defined these populations as follows:

Chronically homeless refers to individuals, often with disabling conditions (e.g. chronic physical or mental illness, substance abuse problems), who are currently homeless and have been homeless for six months or more in the past year (i.e., have spent more than 180 cumulative nights in a shelter or place not fit for human habitation).

Episodically homeless refers to individuals, often with disabling conditions, who are currently homeless and have experienced three or more episodes of homelessness in the past year (of note, episodes are defined as periods when a person would be in a shelter or place not fit for human habitation, and after at least 30 days, would be back in the shelter or inhabitable location).

The definitions of chronically and episodically homeless individuals include all sub-populations, such as Veterans and/or Aboriginals. The definitions also include individuals exiting institutions (e.g. child welfare system, mental health facilities, hospitals, and correctional institutions) who have a history of chronic and episodic homelessness and cannot identify a fixed address upon their release.

Housing, Housing First and Chronic Homelessness

The inability of people to afford to obtain and maintain housing underlies much of our national homelessness problem. Chronically homeless individuals, many of whom have the additional complications of mental health and addictions challenges, are unable to find and afford housing that would provide a platform for recovery.

HPS’s Housing First program with its focus on chronically homelessness individuals is predicated on the idea that with a limited amount of money, priority should first be placed on those in greatest need (chronically homeless persons with mental health and addictions challenges), and that once those numbers begin to decline, resources can be reallocated to other needs.

Housing First (HF) is considered a humane and pragmatic approach to addressing homelessness demonstrating that chronically homeless people can successfully be housed. It began in the United States as a housing response for chronically homeless people suffering from chronic and persistent mental illness. It has grown and evolved over the last twenty years into a very effective housing intervention for a wide range of homeless populations as well as a philosophy around which homeless systems can be organized. Housing First as a program model and increasingly as a system philosophy is now being implemented throughout the western world.

Moreover, when adopted on a mass scale, HF can lead to real reductions in homelessness. The Mental Health Commission of Canada implemented Housing First in the five sites of the At Home/Chez Soi study (Moncton, Montreal, Toronto, Winnipeg and Vancouver) and proved without a doubt that it was an effective intervention for chronically homeless populations.

The At Home/Chez Soi project is the world’s most extensive examination of Housing First and provides perhaps the best evidence to date. The team conducted a randomized control trial where 1,000 people participated in Housing First, and 1,000 received 'treatment as usual'. The results demonstrated that you can take the most hard-core, chronically homeless person with complex mental health and addictions issues, and put them in housing with supports, and they stay housed. Over 80% of those who received Housing First remained housed after the first year. More importantly, for most their well-being also improved. The use of health services declined as health improved and involvement with law enforcement decreased. Part of the recovery orientation of Housing First focuses on social and community engagement and many people were helped to make new linkages and to develop a stronger sense of self.

Does housing chronically homeless persons actually save money?

There is also an economic argument to be made for prioritizing chronically homeless individuals. Keeping people in a continuous state of homelessness is extremely costly. Contrary to popular views that relying on emergency services is cheap and the alternative is too costly, is the reality that those supports on their own are expensive. Though small in numbers, these individuals utilize a large portion of emergency services across the homeless sector but also in health, criminal justice and social services. In terms of shelter use:

“In the case of Toronto and Ottawa, individuals in these two clusters occupied over half of the shelter beds during the four-year period of the study even though they represented only between 12 per cent and 13 per cent of the shelter population” (Aubry et al., 2013:910).

Moreover, beyond the costs associated with emergency services for homeless people, we also have to consider chronically homeless people are more likely to utilize expensive health services (such as more emergency room visits) - because their health becomes extremely compromised while living on the streets (Gaetz, 2012; Hwang and Henderson, 2010; Hwang et al., 2011). In addition, because of law enforcement strategies that essentially criminalize homelessness, considerable resources are spent policing and incarcerating homeless individuals (Kellen et al., 2010; Novac et al., 2006; 2007; Gaetz & O’Grady, 2006; 2009; O’Grady et al., 2011). Keeping people in an ongoing state of homelessness is then not ‘doing things on the cheap’, but rather, is quite expensive.

The best evidence for this is, again, the recent At Home/Chez Soi final report (Mental Health Commission of Canada, 2014) which found that spending $10 on housing and supports for chronically homeless individuals with the highest needs, resulted in $21.72 in savings related to health care, social supports, housing and involvement in the justice system. As the Real Cost of Homelessness concludes: “Solving homelessness makes sense. Not only are we saving money, we are also doing the right thing” (Gaetz, 2012:15).

Chronic Homelessness and Youth

While it is necessary to prioritize high-risk groups such as the chronically homeless, a case can be made that addressing homelessness as a broader social problem requires a more comprehensive approach. Youth with complex needs may not have not been homeless long enough to be considered chronic, but may become chronically homeless without support.

Homeless youth under 25 are a priority for many communities. Making up only 20% of the homeless population, they are nevertheless over-represented. Moreover, there is evidence in Canada and the United States (Baker-Collins, 2013; Nino, et al., 2010; Stein et al., 2002) that for many chronically homeless individuals, their pathway into homelessness began when they were youth and young adults. The causes and conditions of youth homelessness are distinct from that which besets adults, and therefore the solutions should be different as well. Addressing youth homelessness effectively – with age appropriate models of accommodation and supports – may be a chronic homelessness prevention strategy (Gaetz, 2014).